Sunday, January 31, 2010

If this report from the January 30, 2010 edition of The Hill is correct, we may have narrowly averted ObamaCare due to Martin Luther King Day:

Sen. Tom Harkin, the chairman of the Senate Health Committee, said negotiators from the White House, Senate and House reached a final deal on healthcare reform days before Scott Brown's victory in Massachusetts.

...Harkin said "we had an agreement, with the House, the White House and the Senate. We sent it to [the Congressional Budget Office] to get scored and then Tuesday happened and we didn't get it back." He said negotiators had an agreement in hand on Friday, Jan. 15.

Harkin made clear that negotiators had reached a final deal on the entire bill, not just the excise plans, which had been reported the previous day, Jan. 14.

Because of the Monday January 18 was Martin Luther King Day (i.e., a federal holiday), the CBO didn't have a chance to score the bill.

Scott Brown's victory in the Massachusetts special election for Senate the next day (Tuesday January 19) then torpedoed the deal.

I knew this country narrowly averted disaster that week. But I had no idea how close of a call it was...

Basically, the House has to first approve the Senate bill without changes. Then they would use the "budget reconcilation" technique to make changes in a pre-arranged deal to satisfy the various special interest groups. This only requires 51 votes in the Senate, not 60. This tactic is necessitated by the Scott Brown victory in Massachusetts which deprived them of their prior 60-vote supermajority.

The good news is that several Democrat Senators have already expressed opposition to using this method. (Whether they actually vote against it is a separate issue). So the Democrats may only have just barely over 50 votes they can count on. Which means if 1 or 2 more Democratic senators decide to oppose this tactic, then it will fail.

Here's an example of a great letter that David Crawford sent to his Senators from Washington state (reposted with his permission):

Senator XXX,

I have heard news that there is a plan to pass the Senate version of the health care bill with modifications made through "budget reconciliation", which requires fewer votes.

None of this seems to be confirmed, so I don't know what is true, but if there *is* such a plan, it seems to be a total subversion of the legislative process! Please do not support efforts that are obviously intended to force a major new set of laws and regulations on a people who are trying to make it clear that they don't want it.

The Massachusetts election was the latest of many efforts of voters to communicate that we do *not* support this massive intrusion into our health care. I believe the Senate bill was passed too early, without a real understanding of your constituents concerns.

We all want better health care, but the proposed changes may have a devastating effect on the existing system, especially at a time when the economy is still very unstable. Please listen to what your constituents are trying to tell you and vote NO on any "budget reconciliation" efforts to get ObamaCare into law.

Amidst the euphoria by anti-ObamaCare activist over the Scott Brown election victory, Kimberley Strassel warns that some of the underlying principles behind ObamaCare may have gotten a political boost.

...Mr. Brown brazenly turned his Senate bid into a referendum on President Obama's health plan, and voters rewarded him with a job. Yet ObamaCare's model was the health reform inflicted on Massachusetts by a certain Republican governor in 2006, otherwise known as RomneyCare.

That precursor shares many elements of Washington's legislation, from an individual mandate, to employer taxes, to subsidized middle-class insurance. The program has bombed, creating giant costs while realizing minimal benefits. A big reason only 25% of Massachusetts voters strongly approve of ObamaCare is because of this experience.

The state plan has become a millstone for Mr. Romney, yet he has refused to disavow it. Had he campaigned with Mr. Brown he'd have undoubtedly been asked about it, and undoubtedly given an answer as unsatisfying as those to date.

...Mr. Romney has never backed away from his individual mandate, which requires people to buy insurance or pay a fine. Yet Republicans and independents despise the mandate, with many believing it is downright unconstitutional.

Mr. Romney's subsidized coverage is meanwhile doing what entitlements do: crowding out private insurers, compounding the cost explosion, walking the state toward rationing. So long as the former governor clings to these central points of his health plan, he's on the wrong side of free-market policy and public opinion.

That might be why in December Mr. Romney shifted again, saying his program differed significantly from ObamaCare in that it "solved" the "problem" at the state level, and featured no public option. But the public option argument has gone poof. And while GOP primary voters care about federalism, most will be hard pressed to parse the difference between a failed state program and a failed federal one.

The federal government may exercise only the powers granted to it or denied to the states. The states may do everything else. This is why, for example, states may have authority to require individuals to purchase health insurance but the federal government does not. It is also the reason states may require that individuals purchase car insurance before choosing to drive a car, but the federal government may not require all individuals to purchase health insurance.

In other words, they object only to the fact that the federal government would require mandatory health insurance, rather than state governments.

Unless Brown, Romney, and the Republicans disavow the principle of mandatory insurance, we may see it in a new form in a few years.

I would like to think that the Republicans would recognize the importance of arguing these issues in principle. But I won't hold my breath waiting...

Thursday, January 28, 2010

...By the time I'm finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans, and neither should the people in this chamber.

As temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors and stop insurance company abuses, let me know.

I'll offer my $0.02.

At the economic level, if our President wants to lower costs, he should try free market reforms.

At the philosophical level, he needs to re-examine the "morality of need" that says that one person's need gives him a moral claim on the goods and labor produced by another. This IBD editorial by Brook and Watkins is a good place to start.

Wednesday, January 27, 2010

In 1993, New York adopted two of the most popular parts of the health care reform bill that recently passed the Senate: "guaranteed issue," or a rule that insurers must sell to anyone, regardless of pre-existing conditions; and "community rating," which prevents insurers from setting premiums based on characteristics like age and sex. (New York's reform is more radical than proposed federal reforms, as it allows no variance at all on age; the Senate bill would cap the amount of age-based difference).

New York did not require anybody to buy health insurance, nor did it give out subsidies to help people pay for it (though it did expand government-provided insurance at vast taxpayer expense.)

These reforms were supposed to make it possible for more people to get insurance coverage. Instead, what they did was drive premiums through the roof. Now, the cheapest insurance plan for a family in New York City costs $26,040, compared to a national average of around $13,000.

Unsurprisingly, few New Yorkers find these prices affordable, and the share of New Yorkers with individually-purchased coverage has fallen by 96%, to about 2 in 1000. Functionally, New York barely even has an individual insurance market anymore. As a result, New York's rate of uninsurance is in the middle of the pack nationally, even though the state ranks 4th in the share of residents on Medicaid.

New York experienced what is known as an "insurance death-spiral." Under community rating and guaranteed issue, healthy people found insurance premiums to be a bad deal and they dropped out. This increased the average risk among insureds, so premiums rose once more, again driving the healthier and poorer participants to drop. The process repeated itself until almost nobody found it worthwhile to buy their own insurance.

With no clear path forward on major health care legislation, Democratic leaders in Congress effectively slammed the brakes on President Obama's top domestic priority on Tuesday, saying that they no longer felt pressure to move quickly on a health bill after eight months of setting deadlines and missing them...

...[T]wo centrist Democratic senators who are up for re-election this year, Blanche L. Lincoln of Arkansas and Evan Bayh of Indiana, said that they would resist efforts to muscle through a health care bill using a parliamentary tactic called budget reconciliation, which seemed to be the simplest way to advance the measure.

The White House has said in recent days that it would support that approach.

Some Democrats said that they did not expect any action on health care legislation until late February at earliest, perhaps after Congress returns from a weeklong recess. But the Democrats stand to lose momentum, and every day closer to the November election that the issue remains unresolved may reduce the chances of passing a far-reaching bill.

The gear-shift by Democrats underscored how the health care effort had been derailed by the Republican victory in the Massachusetts special election last week, which effectively denied Democrats the 60th vote they need to be sure of overcoming a Republican filibuster in the Senate...

This makes it increasingly likely that the Congress will attempt some "scaled-back" version at the national level. Plus we'll likely see the political battle shift back to the state level.

First, the House will pass the Senate's Obamacare bill that passed the Senate in December. The House leadership will vote on the Senate bill, and Pelosi will allow no amendments or modifications to the Senate bill.

How will Pelosi's deal fly with rambunctious liberal members of her majority who don't like the Senate bill, especially its failure to include a public option, put heavy fines on those who don't get insurance, and offering no income tax surcharge on the "rich"?

That's where the second part of the Pelosi-deal comes in.

Behind closed doors, Reid and Pelosi have agreed in principle that changes to the Senate bill will be made to satisfy liberal House members -- but only after the Senate bill is passed and signed into law by Obama.

This deal will be secured by a pledge from Reid and the Senate's Democratic caucus that they will make "fixes" to the Senate bill after it becomes law with Obama's John Hancock.

But you may ask what about the fact that, without Republican Scott Brown and independent Democrats such as Joe Lieberman, Reid simply doesn't have the 60 votes in the Senate to overcome a Republican filibuster that typically can stop major legislation?

According to my source, Reid will provide to Pelosi a letter signed by 52 Democratic senators indicating they will pass the major changes, or "fixes," the House Democrats are demanding. Again, these fixes will be approved by the Senate only after Obama signs the Senate bill into law.

Reid also has agreed to bypass Senate cloture and filibuster rules and claim that these modifications fall under "reconciliation" and don't require 60 Senate votes.

To pass the fixes, he won't need one Republican; he won't even need Joe Lieberman or wavering Democrats such as Jim Webb of Virginia.

His 52 pledged senators give him a simple majority to pass any changes they want, which will later be rubberstamped by Pelosi's House and signed by Obama.

This plan, of course, is a total subversion of the legislative process...

As I said, I don't know how reliable this report is. But we shouldn't let our guard down yet...

The Washington Times is the latest paper to chime in against the proposed scaled back "insurance reforms" in its January 25, 2010 OpEd, "Faux health reform".

One excerpt:

President Obama and some other Democrats are putting out sounders about scaled-down health regulations. Striking his new populist pose, Mr. Obama told ABC News, "We know that we need insurance reform, that the health insurance companies are taking advantage of people." The problem with the president's anti-business stance is that if enacted into law, it will destroy private health insurance.

You don't have to take our word for it. Liberals like New York Times columnist Paul Krugman are warning about the president's suggestion. Regarding the regulation to forbid insurance companies from taking into account preexisting health conditions, Mr. Krugman wrote, "healthy people [will] choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading even more healthy people dropping out." In other words, proposed regulations would produce more uninsured Americans and higher insurance costs.

To illustrate how bad this idea is, imagine if motorists could buy automobile insurance right after an accident and then were allowed to drop it once the car was fixed. Without revenue from regular premiums, insurance companies couldn't cover all the claims and would go under...

One question -- is that a bug or a feature? In other words, are there some politicians who want to pass this kind of measure knowing that the economic logic will eventually drive private insurance companies out of business? Then they could claim that "the free market has failed" and propose a governnent-run "single-payer" system as the solution.

Monday, January 25, 2010

Now that a comprehensive national-level ObamaCare plan of "universal health care" is unlikely to happen, individual state governments will likely start working on their plans. Of course, the fact that they've failed in the past won't stop the true believers.

California is poised to become the first state to set time limits for doctors to see patients, the Department of Managed Health Care said.

Regulations to be announced Wednesday require family practitioners in health maintenance organizations to see patients seeking an appointment within 10 business days. The deadline for specialists is 15 days.

Of course, if the government could conjure up immediate medical care by fiat, why not do the same for food, water, and housing?

Eventually, reality will catch up with even the most wooly-headed wishful thinking. But for now, California politicians keep dreaming...

Friday, January 22, 2010

Given that there's little political will in Congress to pass the blockbuster ObamaCare bill, the most likely next tactic will be attempting to pass the various provisions in a piecemeal or scaled-down fashion.

One proposed scaled-back version is a law requiring insurers to accept patients regardless of pre-existing conditions.

...[F]orcing insurers to accept all comers without an individual mandate could destroy the economics of the industry. The young and healthy could simply choose not to get coverage until they get sick. States with guaranteed coverage but no mandates are among those with the highest premiums in the nation.

If there's an individual mandate, the government would likely feel compelled to provide major subsidies to help lower- and middle-class Americans afford care. And financing such a bill would require big spending and/or tax hikes. And that would bring Democrats back to where they were before Tuesday.

It would be the equivalent of not having any car insurance, hitting a tree, and then calling Geico and saying you want to sign up. It doesn't make sense.

Instead of more government controls over insurance, we need a free market. Insurers should be able to offer policies on terms based on their own best judgement and prospective customers should be free to purchase (or not purchase) those policies based on their own best judgment.

Furthermore, if patients were unhappy with current insurance offerings, a free market would permit them to form their own risk pool and essentially self-insure. It is only onerous government regulations that prevent willing individuals from voluntarily forming their own insurance companies as they see fit. Instead, they have to abide by all the regulations and restrictions of their state insurance commissioner.

A fully free market would protect individuals' ability to purchase insurance, whereas imposing still more restrictions on whom insurers must cover and what benefits they must offer would actually destroy it.

For more information on this, please see my article from the Fall 2009 issue of The Objective Standard:

In the wake of the Massachusetts special election, Bryan Armentrout sent the following letter to his elected officials (reposted here with his permission):

I oppose any effort by the government to control my healthcare and I hope that the developments in Massachusetts will serve as a clear wake up call at your office. No one wants this legislation and the elections and polls strongly support this assertion.

I urge you to reverse your support and publically oppose healthcare legislation in any form.

If you continue your support for nationalized healthcare, I will actively work to remove you from office during the next election cycle.

Thursday, January 21, 2010

My theme is that the recent election in Massachusetts (as well as the earlier November 2009 elections in NY, NJ, and VA) show that independent voters want limited government. Specifically, they want "the Democrats out of their pockets and the Republicans out of their bedrooms."

Here's the opening:

In the aftermath of Scott Brown's stunning upset election victory in Massachusetts, pundits will be debating the meaning and political implications for weeks to come. However, one fact is incontrovertibly clear. The race hinged on the independent voters.

In Massachusetts, 50% of the registered voters are independent, as opposed to 37% Democratic and 12% Republican. In this week's election, independents voted overwhelmingly for Brown, giving him a 52-to-47% victory -- in a state where Barack Obama easily won 62% of the vote in 2008. This enormous swing shows that the independents represent a powerful political force that neither party can take for granted.

Independents are also the driving force behind the tea party rallies. Many tea party supporters have been quite explicit in warning that their opposition to the policies of our current Democratic president and Congress should not be mistaken as automatic support for the Republicans.

Wednesday, January 20, 2010

In general, I very much like his emphasis on allowing physicians and other practitioners to engage with patients using social media, without fear of legal repercussions. I know many physicians are reluctant even to use e-mail, precisely because of legal concerns.

I would like to emphasize that in a free market, one would not need to mandate price transparency, as this would follow as a natural consequence of providers and patients each seeking their rational self-interest. Conversely, price transparency without a free market (for instance, in the type of heavily-regulated insurance market that Obama wants) would be meaningless.

As one small point of dissent, I think it's important not to conflate political power of governments with the economic power of corporations.

A disastrous intellectual package-deal, put over on us by the theoreticians of statism, is the equation of economic power with political power. You have heard it expressed in such bromides as: "A hungry man is not free," or "It makes no difference to a worker whether he takes orders from a businessman or from a bureaucrat." Most people accept these equivocations—and yet they know that the poorest laborer in America is freer and more secure than the richest commissar in Soviet Russia. What is the basic, the essential, the crucial principle that differentiates freedom from slavery? It is the principle of voluntary action versus physical coercion or compulsion.

The difference between political power and any other kind of social "power," between a government and any private organization, is the fact that a government holds a legal monopoly on the use of physical force.

I fully support limiting the power of government to its proper function of protecting individual rights. Otherwise, Dr. Hennefent is correct -- we would end up with rationing and "death panels".

In contrast, any economic power of insurers in a free market would be controlled by the voluntary actions of patients and providers who would be free to deal with (or not deal with) insurers based on their own rational self-interest. The government should only intervene if the insurance companies are guilty of commiting fraud or initiating force.

Although we're still a long ways away from genuine free market reforms, last night's election may have halted the momentum towards a seemingly-inevitable government takeover of medicine. Perhaps now, some genuine free market reforms can be part of the health care debate.

...This is the clarity that Obama has brought to the American political scene. To see a president’s clear and principled commitment to an ideology -- any ideology -- is precisely what America has needed for decades. This sight has helped many people understand the issues at a more fundamental level than they ever have.

Obama and his congressional allies have unwittingly launched a grass-roots movement that is actively questioning the role of government in our lives. Although a large portion of the protesters remains confused about the principles at stake, an increasing number are gaining clarity. They are coming to see the Democratic proposals for health-care "reform," for instance, not as a matter of new programs backed by good intentions, but as an attack on individual rights and an effort to impose a dictatorship -- as signs at tea parties attest. And many are beginning to see that the Republicans as well have been guilty of such attacks.

...Many Americans are now able to see Obama's plans as an assault on the founding principles of this nation. In addition, many Americans realize that time is running out -- that the future is here, today. These two factors are energizing otherwise nonpolitical Americans to literally rally around the flag, to confront their elected representatives, and to turn against the administration in droves.

Last night, the people of Massachusetts spoke loud and clear to express their rejection of ObamaCare and the underlying ideology.

Brown may not be a perfect candidate, but his election will buy supporters of free markets and individual some valuable time to promote our ideas.

2) On January 1, 2010 Washington made hidden cuts to Medicare by altering its billing codes.

3) Medicare will cut physician reimbursement by another 21% on March 1. The CBO said this cut must take place if the Senate healthcare bill was to "reduced the deficit."

4) Even more, Congress pledged to cut Medicare by yet another $500 billion. Again, the CBO said this additional cut must take place if the Senate healthcare bill was to "reduced the deficit."

Many physicians were operating at a loss even before this series of massive cuts. In 2008, Mayo Clinic posted an $840 million loss in caring for Medicare patients. No businesses can survive when patient care expenses exceed revenue.

The second is more ominous -- Washington’s increasingly abusive posture toward physicians.

President Obama reflected this attitude last summer. On national television, he stated as fact a surgeon is paid between $30,000 and $50,000 for amputating a patient’s foot.

In reality, a surgeon is paid between $740 and $1,140 to perform this unfortunate, but often life-saving procedure. This reimbursement must cover a pre-operative evaluation the day of surgery, the surgery, and follow-up for 90 days after surgery -- not to mention malpractice insurance, salaries for clinic nurses, and clinic overhead. It is frightening to think our president is so wildly misinformed even as he stands on the cusp of overhauling American health care. But it gets worse.

In particular, Dr. Gray discusses some of the abusive new audits under the program called RAC (Recovery Audit Contractors). One example of such audit abuse against a physician group:

For example, one patient the auditor alleged the group had "fraudulently" billed for was a man undergoing a chemical stress test. The allegation was the patient should have undergone a cheaper traditional treadmill stress test. The difficulty with this accusation was this man was a double amputee -- he had no legs. This made a traditional treadmill test impossible. The auditors clearly were not trained health care professionals -- they were bounty hunters. (It is worth noting the investigators are given legal immunity from a countersuit for conducting a "fraudulent investigation.")

This story is not unique. To reduce Medicare's budget shortfall physicians are being subjected to these abusive investigations nationwide. If medicine increasingly falls under government control, why should the best and the brightest of our youth give up 15 years of their life to go into medicine?

The Wall Street Journal warns us that under ObamaCare, we may see yet another "czar" -- this time, in charge of our mandatory health insurance. This would be in addition to the long list of czars President Obama has already appointed for "green jobs," executive pay, domestic violence, international climate change, and the auto industry.

Under any system of mandatory insurance, the government must necessarily determine what constitutes an "acceptable" plan. The health insurance czar would be in charge of a new bureaucracy called the "Health Choice Administration," which would regulate what prices insurance companies could charge for policies, who they must cover, and what benefits they must offer...

As Obama Care becomes closer to reality, we in Colorado have the right to say "No." This is a chance for freedom loving people from across the state to come together and send the Colorado General assembly a simple message: Defend Colorado against Obama Care in the legislature, or we the people will do it at the ballot.

At the rally, we will be introducing language for a ballot initiative to amend the Colorado Constitution to excempt Colorado from Obama Care. We need to send a very strong and unified message to lawmakers that while we want them to say yes to defending Colorado, we are also ready, willing and able to move forward with the citizen initative process should the legislature fail us.

...Jon Caldara and the Independence Institute moved Colorado another step toward its own brand of health care reform, filing with state officials a proposed amendment to the Colorado Bill of Rights called the "Right to health care choice."

...The amendment would forbid government from forcing individuals to buy private health insurance -- an attempt to counter proposed federal legislation. It would preserve the rights of individuals to pay cash for health care services, and it would uphold the right of Coloradans to buy health insurance plans from providers in other states.

The House and Senate versions of proposed federal health care reform would greatly restrict the rights of individuals to make their own health care decisions. The proposed amendment, if upheld by the courts, could make Colorado a unique enclave of health care freedom of choice.

From the wildly improper gifts to senators like Nebraska's Ben Nelson to this week's backroom deals for unions, the so-called health care reform emerging from Washington has become bad medicine for America and ought to be rejected. Quickly.

Unbelievably, the bill got even worse this past week when lawmakers agreed to exempt union workers from paying taxes that other workers will have to pay for years.

Colorado Sens. Mark Udall and Michael Bennet ought to take a principled stand against the failed reform effort, even if it once held promise.

I'm glad to see that the corrupt favor-trading and deal-making has become so apparent that even supporters of "universal health care" are against this particular bad proposal.

If by some political miracle ObamaCare is defeated, another version will inevitably be proposed. But at least it will have bought more time for free-market advocates to continue to make their case to the American people and our elected officials.

Willing patients should be able to purchase lab tests without having to go through a physician. The AMA (American Medical Association) is wrong on this issue, and that's another reason I'm not a member.

Instead of taking a principled stand against government regulations (and for free market reforms), they're probably thinking they can sway the political process to their liking by supporting (appeasing?) the greater statist now. If history is any guide, they'll soon learn the error of their ways. It's too bad we'll also have to pay the price for their folly.

...[W]ith individual patients losing even nominal control of their medical dollars, the health care system will be powered less by patient needs, and more by collective social goals dictated by politicians driven by powerful lobbies adept at political marketing.

Patients who lack the political savvy or represent disfavored causes -- obesity, smokers, homosexuality -- inevitably get relegated to second class medical status. If money poses an unfair obstacle for patients in a market-based system as progressives allege, can they with a straight face claim that the political establishment doesn't pose a far bigger obstacle in a government-run system?

But it is not just patients who are pitted against each other; providers are too. Unlike in a market where competition and innovation is always expanding the medical pie, in a nationalized system providers are engaged in a zero-sum game. Every dollar that goes for reduction of infant mortality to a pediatrician is one that doesn't go to a neurologist for Parkinson's treatment.

Since there is no equitable formula to deal with all these competing claims, politicians under nationalized health care are constantly tinkering and experimenting to fashion the system after their own pet causes. Even basic questions as to whether a health care system should be more cost-effective or more accessible become subject to political whim...

...An expansion of Medicaid, subsidies for those with low income, an insurance exchange, a mandate for individuals to buy insurance -- all of these ideas that are core to Obamacare already passed in the Bay State a few years ago.

And, by all accounts, the experiment has been problematic. Yes, the total number of uninsured has dropped. But insurance premiums soared, boasting double-digit annual increases. The Boston Globe recently proclaimed that Massachusetts now has the highest insurance costs in the country.

Needless to say, state officials are at a loss -- and on the hook. Program spending is about 85 percent higher than originally projected. Recently discussed proposals include a return to managed care-like capitation and even price controls.

...As [Massachusetts officials] were implementing the plan, they insisted that basic health insurance cover countless services and offer wide subsidies. In other words, for a health system plagued by subsidies and regulations, officials decided to offer up more of the same.

Hence, for supporters of individual rights, Scott Brown may be a lesser of two evils compared to his opponent Martha Coakley (who would vote for ObamaCare).

At this point in time, an inconsistent "mixed" supporter of individual rights would be better than an avowed opponent. But it sure would be nice to have some consistently principled supporters of individual rights holding national office.

Mchangama summarizes some of the legal theories used around the globe to allegedly justify the concept of a "right" to health and health care.

I was particular struck by his discussion of how this plays out in Brazil:

...Brazil's constitution explicitly recognises the right to health, but many patients who call upon the state to fulfill this obligation are frequently met with shortages and stockouts in state pharmacies.

Many of these patients have therefore -- quite reasonably -- responded by suing the government. The right to health has therefore led to an explosion of judicial challenges by patients against the government, with more than 1200 cases of judicial review sought in the Rio Grande do Sul region alone each month.

Such claims act as a major burden on the judicial system as well as a heavy fiscal burden on the government.

There are also severe ramifications for equity. Rather than making access to healthcare universal, in Brazil the enforceable right to health has had the perverse consequence of favouring the politically connected or those who can afford the high cost of judicial review.

Turning healthcare into an individual enforceable right creates all kinds of legal complexities, undermines the rule of law and stifles political pluralism. Neither is there any evidence that "the right to health" has actually improved healthcare anywhere in the world -- in some cases it has undermined it.

In reality, the rights which are really fundamental to improved healthcare are those which underpin prosperity and economic development -- such as the right to own and exchange property. Such rights are denied to millions, yet are vital for creating the prosperity needed to pay for good healthcare.

(Note: I don't know anything about the IPN other than what I've seen in this article. But I'm glad ideas like these are being discussed at the international level.)

...The Nobel Prizes in medicine and physiology have been awarded to more Americans than to researchers in all other countries combined.

Eight of the 10 top-selling drugs in the world were developed by U.S. companies.

The U.S. has some of the highest breast, colon and prostate cancer survival rates in the world. And our country ranks first or second in the world in kidney transplants, liver transplants, heart transplants, total knee replacements, coronary artery bypass, and percutaneous coronary interventions.

We have the shortest waiting time for nonemergency surgery in the world; England has one of the longest. In Canada, a country of 35 million citizens, 1 million patients now wait for surgery and another million wait to see specialists.

Yes, the US health system has problems. But any kind of government takeover will simply make things worse, not better.

8 out of 10 Americans are happy with the quality of the care they receive. Let's not destroy our current system by a headlong rush to "universal health care".

...[T]he changes proposed to all health insurance policies could have potentially adverse affects on high deductible health plans (HDHPs) that currently make people eligible to contribute to HSAs. Some of the impact may not be known until regulations implementing the final provisions are written.

...Another new requirement for all insurance policies is that they provide a minimum actuarial value for the benefits covered.

Under the House bill, the minimum actuarial value must be at least 70 percent. Under the Senate bill, the minimum actuarial value must be at least 60 percent. Given the higher deductibles that most HDHPs have (compared to traditional HMO and PPO plans), the lower minimum actuarial value requirement in the Senate bill would make it easier for more HDHPs to meet the standard.

...It is also not clear whether a plan's actuarial value would include employer or individual contributions made to the individual's HSA.

The House bill is completely silent on this matter which would leave it up to the Secretary of HHS to define in regulations. The Senate bill requires the Secretary of HHS to issue regulations on this matter.

Including the contributions in the calculation of a plans actuarial value would make it easier for more HDHPs to meet the minimum actuarial value requirement. If contributions are not included, HDHPs, many of which have actuarial values below 60 percent (or whatever the final standard becomes) based on the insurance coverage alone, could no longer be sold.

In essence, the Secretary of Health will have the discretion to determine whether you are allowed to use a Health Savings Account to take care of your insurance needs. Instead of a "rule of law", we'll have "rule by men" with enormous latitude to decide whether you can spend your own money as you see fit to protect your own life and health.

This is just an application of the basic principle that we've already seen in Massachusetts. When government makes health insurance mandatory, the government must also necessarily determine what constitutes an "acceptable" policy. This means depriving individuals of the ability to choose plans (such as HSA's) that they might consider in their best interest. Instead, government will force Americans to spend their money as the government sees fit.

In my experience as a practicing physician, that's pretty typical for American health care.

Pitts then noted:

I used Facebook to let my friends and family know about my wife's condition.

The Americans were all appropriately sympathetic.

The Europeans -- who suffer under socialized medicine -- were mostly amazed.

Amazed that we didn't wait hours for an emergency-room bed.

Amazed that we saw a doctor in less than five or eight hours.

Amazed that we weren't told to go home and come back at a later date -- because her white-blood-cell count was only slightly elevated and the appendix wasn't in danger of bursting.

And not amazed but astounded that the surgery was done immediately. That there was actually a room available and that it was vacant -- at a large urban hospital -- they couldn't even fathom.

Here is one verbatim comment from a continental comrade:

"I waited three days in London to see a GP and 20 hours at ER for an 'exploratory op.' It burst and I nearly died (to say nothing of the two life-threatening incidents whilst I was being 'cared' for). But hey! The public option is better... right?"

Are health insurance companies evil? A web search for the phrase turns up almost a million hits. The common reasons for this passionate indictment are insurance company profits, denial of claims, and rescission of policies. But these do not justify the Democrats’ goal of expanding political control of health insurance. Rather, they call attention to existing controls that unfairly advantage insurers and limit competition that would keep insurers honest. They also suggest government’s failure to enforce contracts.

...The federal government wants to require young, healthy people to buy insurance because if they don't, premiums for everyone else will go up.

Insurance companies need low-maintenance, young customers on their rolls so they can raise money to cover benefits for less-healthy people the health care bill will require them to insure.

..."If you charge people a fair price, then a 50-to-60-year-old should pay about six times as much as a 20-year-old," said John Goodman, president of the National Center for Policy Analysis.

But he noted that the Senate bill says older people can be charged only three times as much; the House bill says they can be charged two times as much. "So we're going to penalize low-income young people in order to lower the premiums for older wealthier people."

...Young, healthy adults are the most unjustly affected by mandatory insurance. These patients consume the fewest medical resources and therefore, under mandatory insurance, most heavily subsidize the costs of the older, more-frequently-ill patients.

Mandatory insurance robs them of money they could use for their own goals, such as saving to buy a first house or to start a business or a family. Hence, mandatory insurance forces them to sacrifice their lives and futures for the sake of the collective.

Mandatory insurance represents a huge forced transfer payment (or "taking") from young people to senior citizens.

Could this be one reason that the AARP (the lobbying group for seniors) loves ObamaCare?

Thursday, January 7, 2010

In the January 6, 2010 Denver Post, Vince Caroll points out what should be obvious to everyone (except Congressmen), "Free preventive care? Hardly".

Here's an excerpt:

If the Senate health care bill becomes law, your preventive care will become "free." Now, now: Don't go raising a quizzical eyebrow. We have the word of Colorado Sen. Michael Bennet that the bill guarantees "free preventive care for everyone."

...What the senator actually meant, of course — and would eventually get around to explaining in the speech -- is that the bill mandates preventive care "without co-payments."

Meaning you won't pay for preventive care directly. You'll pay for it indirectly through higher premiums, higher co-pays for other services or higher taxes and greater national debt.

And to promise this "free care", the government must also assume control over who can receive it and when:

...The details of the preventive-care mandate in the Senate bill (there's a similar one in the House bill) offer the clearest lesson yet of how Washington intends to micromanage health insurance. Forget about meaningful choice. It won't be too many years before you will enjoy the same choice that Henry Ford touted for the Model T: any color at all, "so long as it's black."

...Whether Washington bureaucrats or politicians set the rules, however, the net result still will be an unprecedented level of micromanagement of medical coverage, according to Edmund Haislmaier of the Heritage Foundation -- far beyond the existing regulations of any state.

Note: FIRM is a non-partisan project. Therefore, this should not be construed as any kind of endorsement of Mihos or any other political candidate.

However, it is noteworthy that Mihos has offered both a good diagnosis of today's health policy problems and some important free-market solutions:

...First and foremost, our reforms were based on the faulty notion that health care is some sort of "right" which must be guaranteed by the government. Rights are not entitlements to goods or products that must be produced by another. There is no such thing as a right to a car, or a tonsillectomy. Instead, we have the right to be left alone and purchase as much or as little health-care as we choose.

Our state's current problem are the results of policy makers, bureaucrats, lobbyists, and insurers (a few of which are my opponents) violating this basic right and limiting our freedom to purchase what we want and from whom. Now, we are forced to choose from a limited set of insurance plans on terms set by Beacon Hill and special interest, rather than ourselves.

His proposed solutions include:

We should repeal all laws such as community rating and guaranteed issue, which have made Massachusetts' insurance rates amongst the highest in the country. Instead, our state should allow people to buy more affordable coverage that is available in other states. By allowing insurance companies to compete across state lines, this would immediately make the best offerings of all 50 states available to Massachusetts residents. This plan also has the potential to dramatically cut insurance expenses for many residents.

I also want to allow people to set up health savings accounts (HSAs) for routine expenses and purchase catastrophic-only insurance for major expenses. Under our current system, HSA-qualified plans are unaffordable and essentially illegal. These reforms would empower patients and lower costs by making patients not just the consumers, but paying customers of medical care and insurance.

I don't know anything else about Mihos beyond what's on his website, and I haven't done any significant research into his positions on other issues. Hence, this should not be construed as any kind of endorsement of his candidacy.

But I am glad that at least one Massachusetts political candidate is seriously considering free-market health care reforms. And I hope that other candidates (both in MA and the rest of the country) start discussing and debating these ideas as well.

...Never before has the federal government intruded into decisions made by doctors for privately insured patients, except on narrow issues such as drug safety. Nothing in the Constitution permits it. But the Senate bill makes you enroll in a plan and then says that only doctors who do what the government dictates can be paid by your plan.

"Qualified plans" can contract only with a doctor who "implements such mechanisms to improve health-care quality as the [current or future] secretary [of Health and Human Services] may by regulation require" (Sec. 1311, p. 148-49). That covers all of medicine, from heart care to child birth, stents to mammograms.

...In the 13 years since I joined the NHS, conditions have deteriorated. Starting from the moment they arrive through the hospital doors, birth plans tucked neatly in their overnight bags, women are being betrayed.

There is reams of evidence to prove that a woman's labour is likely to be shorter and she runs less chance of needing medical intervention if she feels calm and relaxed in the early stages. It's not rocket science.

Yet because midwives don't have time to sit with women in early labour for more than a few minutes at most, we are encouraged to do the next best thing.

We offer them strong painkilling drugs such as pethidine or diamorphine -- which is a form of heroin.

Drugs keep the mother nice and quiet which, of course, suits staff.

But they also likely to make her and her unborn baby terribly sleepy.

Although these drugs can sometimes increase contractions, they all too often slow them down.

The end result at the woman will need more drugs, not fewer, and labour will take longer.

But, of course, we don't explain of that as we dole out our pain killers. Besides, on a busy ward, what's the alternative?

Once a woman is in full labour, you'd thought we'd put her needs first. But I'm embarrassed to admit that, all too often, we were not allowed to.

Most hospitals rigidly enforce the rule that, once in labour, a woman's canal must dilate at the rate of 1cm an hour.

If that isn't happening, midwives are encouraged to tell the her that her baby may be getting in distress -- even if that isn't the case.

Terrified and exhausted by a haze of drugs, the woman agrees to anything which is offered.

In practice, this means we give her extra drugs to intensify the contractions and so speed the arrival of the child.

Her pain levels increase and she'll need an epidural injection in her spine to numb the pain around her groin.

It's a vicious circle. I felt terribly mean persuading women to go along with it. I knew I wasn't always acting in their best interests. But what could I do?

Basically, the NHS system created incentives in which providers were encouraged to act against their patients' interests.

Whenever the government attempts to provide a service such as "universal" health care, it must also control it. This means controlling the doctors, nurses, midwives, and others who will provide that service. As Ms. Brown's story illustrates, the government's priority will inevitably be cost control, even if it means compromised patient care.

Do Americans really want a system where doctors are constantly forced to choose between the priorities of their paymasters and their patients?

National health care works great... so long as you're rich enough to afford the premium level of government insurance and to buy multiple additional private policies; so long as you have influential relatives; and so long as you're willing and able to brazenly bribe the doctors and bureaucrats who run the system.

President Obama suggested last summer that the Mayo Clinic was the model for government medical care. On Monday, the Mayo Clinic in Arizona stopped taking Medicare patients. Now what?

If the nonprofit Mayo Clinic is "what works," as the president believes, then it's clear that government health care doesn't. If Washington can't manage a system with fewer than 50 million participants well enough for those who paid for it to get care, then it sure can't run a program that will eventually include every person in the country.

...One, no American who has paid into the Medicare system for his or her entire working life wants to begin paying for health care out of his or her own pocket. It's cruel to force workers to fund a system they can't draw benefits from.

Two, doctors everywhere, not just at the Arizona Mayo Clinic, are dropping Medicare patients because of the government's meager reimbursements. And the pace of doctors opting out of the system will only pick up if $500 billion is slashed from Medicare funding, as is planned in Washington's health care reform, putting even more elderly Americans at risk.

Either directly or indirectly, Medicare patients will continue see their medical care ratcheted down (i.e., rationed), likely in the name of "cost effectiveness".

And if ObamaCare is passed into law, a similar dynamic will occur with the rest of America.

Monday, January 4, 2010

Jason Crawford has started sending the following letter to his elected officials. With his permission, I am posting his text below:

Dear _______,

I am opposed to the health care bill for several reasons:

First, I just read an important editorial in Saturday's Wall Street Journal explaining why the health-care bill is unconstitutional in multiple ways. In particular: "the Constitution does not give Congress the power to require that Americans purchase health insurance."

Further, I oppose a mandate to buy insurance from a company where I can't negotiate freely.

Finally, I oppose any further restrictions on abortion rights.

In general, I oppose socialized medicine, "universal coverage", any "public option" or "single-payer" system, and any expansion of government control over health care.

Real reform would be increased freedom in health care, especially repeal of insurance mandates, opening insurance across state lines, and opening HSAs to everyone.

Health care is not a right! It is a service to be bought and paid for. And doctors, hospitals, and patients should have the right and the freedom to deal with each other any way they want.

- Jason A. Crawford

I encourage anyone who agrees with his ideas to send something similar to their elected officials. You can find their contact information at:

Individual Mandate Tax: Starting in 2014, anyone not buying “qualifying" health insurance must pay an income surtax of up to $1,485.

Hike in Medicare Payroll Tax: For self-employed idividuals, the Medicare tax jumps from 2.9% to 3.8%. For businesses with employees, a firm’s "matching" Medicare tax jumps from 1.45% to 2.35% of employee salaries.

Employer Mandate Tax: If an employer does not offer health coverage, and at least one employee qualifies for a health tax credit, the employer must pay an additional non-deductible tax of $750 for all full-time employees.

The Mayo Clinic, praised by President Barack Obama as a national model for efficient health care, will stop accepting Medicare patients as of tomorrow at one of its primary-care clinics in Arizona, saying the U.S. government pays too little.

More than 3,000 patients eligible for Medicare, the government's largest health-insurance program, will be forced to pay cash if they want to continue seeing their doctors at a Mayo family clinic in Glendale, northwest of Phoenix, said Michael Yardley, a Mayo spokesman.

...Mayo's move to drop Medicare patients may be copied by family doctors, some of whom have stopped accepting new patients from the program, said Lori Heim, president of the American Academy of Family Physicians, in a telephone interview yesterday.

"Many physicians have said, 'I simply cannot afford to keep taking care of Medicare patients,'" said Heim, a family doctor who practices in Laurinburg, North Carolina. "If you truly know your business costs and you are losing money, it doesn't make sense to do more of it."

On the other hand, if the government sets payment rates so low that patients no longer receive care, think of how much money they'll save!

1) The individual mandate falls outside of various Congressional powers typically used to justify the mandate -- such as the power to "tax and spend", the power to regulate interstate commerce, and the "general welfare" clause.

2) The various state-specific deals that were cut with individual Senators to secure the 60 vote run afoul of the general welfare clause.

There's an election coming up in Massachusetts to replace Senator Ted Kennedy. Properly waged by the Republican, Scott Brown, it could become a perfect storm of the health care debate.

Sissy Willis proposes that it be made a referendum on the potential national catastrophe being masticated by Congress, with the latest milestone the corrupt passage of the Senate version as early coal in the nation's stocking on Christmas Eve. It has the potential to be a brilliant political move.

I believe Simberg is right -- this could be a golden opportunity for the Republicans.

But this would depend on whether the Massachusetts GOP chooses to fight for the right principles, or whether they're content to "me too" the Democrats and merely offer statism-lite as an alternative to ObamaCare.

I believe that all Americans deserve health care coverage, but that we shouldn't have to create a new government insurance program to provide it. I support strengthening the existing private market system.

In Massachusetts, I support the 2006 healthcare law that expanded coverage, but I believe the Deval Patrick administration must do more to contain the costs of the Commonwealth Care subsidy program.

In other words, the candidate himself is not opposed to the basic principles of RomneyCare, based on mandatory insurance. Hence, there's no reason to believe he would be opposed to the national version in the form of ObamaCare.

Hence, I think the GOP will almost certainly refuse to take advantage of this opportunity.

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.